Name, Address, Date Incurred, Amount of reimbursement, Explanation of funds to be reimbursed to parties other than vendors

Person Submitting Reimbursement Request *REQUIRED

Date of Submission *REQUIRED

Please note that the equipment purchased using grant funds is the property of the Ogallala Public School District. Grant funds will be distributed only after sufficient documentation of expenses has been provided to the Foundation's Board of Directors for review via a properly completed reimbusement form. Any unused grant funds will remain with the Ogallala Public School Foundation.